AIM-HI Practice Manual - Make fitness the treatment of choice for prevention and management of chronic conditions.
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AIM-HI Practice Manual
Make fitness the treatment of choice for prevention
and management of chronic conditions.
Americans In Motion - Healthy Interventions
Authors: Sarah A. McMullen, MEd, CHES American Academy of Family Physicians Michelle May, MD, FAAFP Am I Hungry?, P.L.L.C. Mindful Eating and Weight Management Program Elizabeth W. Staton, MSTC American Academy of Family Physicians National Research Network Wilson D. Pace, MD American Academy of Family Physicians National Research Network Mary L. Theobald, MBA American Academy of Family Physicians Janet Ann McAndrews, MPH, CHES American Academy of Family Physicians Contributors: Caroline M. Apovian, MD, FACN Boston University School of Medicine Karen Cox, MS, RD, CLC Colorado Department of Public Health and Environment Laura B. Hansen , PharmD, FCCP, BCPS University of Colorado at Denver and Health Sciences Center Karen Hahn, MA American Academy of Family Physicians Nathan K. LeBrasseur, PT, PhD Boston University School of Medicine Brian Manning, MPH, CHES American Academy of Family Physicians Zori Rodríguez, MA American Academy of Family Physicians © 2013 American Academy of Family Physicians Americans in Motion-Healthy Interventions is sponsored by the American Academy of Family Physicians and is supported by the American Academy of Family Physicians Foundation, National Dairy Council, Nature Made, and The Coca-Cola Company.
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Talking With Overweight and Obese Patients . . . . . . . . . . . 12
The Eating Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Fostering a Healthy Office. . . . . . . . . . . . . . . . . . . . . . . . . 3 The AIM-HI Fitness Inventory and Fitness Prescription. . . . 14
Cultivate Champions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 AIM-HI Fitness Inventory Reproducible Sample. . . . . . .15
Develop a Fitness Culture and Show It Off! . . . . . . . . . . . . . . 3 AIM-HI Fitness Prescription Reproducible Sample. . . . . 17
Create Fitness Support Teams. . . . . . . . . . . . . . . . . . . . . . . . 3 AIM-HI Food & Activity Journal Reproducible Sample. . . . .18
Activate a Staff Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Use the Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Increasing the Likelihood of Success . . . . . . . . . . . . . . . . . . 19
Ideas for Creating a Healthy Office. . . . . . . . . . . . . . . . . . . . . 4 Following Up With Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Addressing Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Integrating Fitness Into Your Practice. . . . . . . . . . . . . . . 5 Cultural Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Assess Your Practice’s Environment. . . . . . . . . . . . . . . . . . . . 5 Health Literacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Be Sensitive to Obese Patients’ Needs. . . . . . . . . . . . . . . . . . 6
Adjust Office Processes and Procedures . . . . . . . . . . . . . . . 6 Foundations for Fitness. . . . . . . . . . . . . . . . . . . . . . . . . 22
Patient Visit Flow Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Physical Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Establish a Referral System . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Healthy Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Get Paid (Reimbursement). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Emotional Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Physical Activity and Emotional Health. . . . . . . . . . . . . . . . . 22
Working With Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Nutrition and Emotional Health. . . . . . . . . . . . . . . . . . . . . . . . 23
The Teachable Moment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Sleep and Emotional Health . . . . . . . . . . . . . . . . . . . . . . . . . . 23
The Patient-Centered Conversation. . . . . . . . . . . . . . . . . . . . 10 Improving Emotional Health. . . . . . . . . . . . . . . . . . . . . . . . . . 24
Stages of Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 AIM-HI Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Americans In Motion - Healthy Interventions
1
Introduction
Family physicians and their practice teams play a vital role in encouraging
patients to lead healthy lives through physical activity, healthy eating and
emotional well being — that is, through fitness. Your practice has taken a
major step toward improving your patients’ fitness by participating in AIM-HI.
FITNESS: physical activity, healthy eating
and emotional well-being
Americans in Motion-Healthy Interventions (AIM-HI) presents fitness as
“the treatment of choice” for prevention and management of many chronic
conditions. AIM-HI was developed by family physicians for family physicians
and the family medicine office environment. In part, this approach was
adapted from “Am I Hungry?,” a multidimensional program developed by AIM-HI is a healthy
family physician Michelle May, MD.
lifestyle program to help
Create a fitness focus in your practice through implementation of these
critical strategies: prevent and manage
• Raise awareness among clinicians and office staff regarding their own overweight, obesity, and
personal physical activity, healthy eating, and emotional well-being, and many chronic conditions.
encourage everyone to make changes for better health. This is covered
in “Fostering a Healthy Office.”
• Create an office environment that is conducive to integrating AIM-HI
concepts in everyday office routines. This is covered in “Integrating
Fitness Into Your Practice.”
• Use the AIM-HI philosophy and tools to help your patients improve their
fitness. This is covered in “Working With Patients.”
• Improve clinician and staff knowledge of the central role of physical
activity, healthy eating, and emotional well-being in health. This is covered
in “Foundations for Fitness.”
The AIM-HI approach relies on three critical tools that all family medicine
practices are encouraged to adopt:
1. AIM-HI Fitness Inventory — a brief survey that captures patients’
confidence about their personal fitness. It also provides a snapshot of
their readiness to change.
2. Fitness Prescription — a contract between patient and clinician
that uses simple, measurable, mutually agreed upon goals that are
AIM-HI Works!
assessed periodically.
3. Food & Activity Journal — a week-long journal that patients can use to AIM-HI Works!
track their physical activity, nutrition, and emotional well-being.
AIM-HI Works!
On the AIM-HI website, www.americansinmotion.org, you will find
AIM-HI
AIM-HImeans Works!
to take care of yourself.
supplementary patient education handouts you can use to stimulate
AIM-HI does not necessarily mean you
dialogue with patients. Feel free to expand on the AIM-HI concepts and
have to lose weight to feel better. Healthy
materials to suit your practice and patient populations.
choices make you feel better.
Implement AIM-HI sequentially, as presented in this manual. The goal is to Cynthia Yates Martin, RN
maximize awareness and integration of AIM-HI steps at the practice level Case Manager, OB Nurse Educator
before you adopt strategies at the patient level. Family Care Health Center
St. Louis, MO
2
Fostering a Healthy Office
AIM-HI encourages clinicians and staff to “walk the talk” 3. Create Fitness Support Teams
and become active participants in making simple changes Establishing fitness teams or fitness buddies will help
in their own lives, creating a healthy office. Your practice keep staff motivated and engaged. Team members
may reap a number of benefits: provide each other a sense of belonging, motivation, and
•Increased credibility — Patients perceive clinicians encouragement.
who practice healthy personal behaviors as more
credible and better able to motivate them to make 4. Activate a Staff Challenge
healthy lifestyle choices. Encourage friendly internal competitions or group activities
•Increased motivation to help patients — Practice related to fitness. Friendly competitions among staff can be
members who actively engage in improving their own motivating and highly effective for building camaraderie and
fitness are more motivated to provide fitness counseling encouraging fitness. The
to their patients. champion can create
•Improved health — Making small changes in your own a chart that tracks
habits can add up to better health and well-being. team progress and
shows patients you are
•Improved morale and teamwork — Working for a involved in change.
common cause will provide staff the opportunity to
share a personal experience, which can strengthen If your team sets up
working relationships. friendly competitions,
ensure that they are
Create a culture of fitness that is supportive, productive
not solely focused
and visible to patients. Consider the following strategies to
on weight loss, since
begin the process:
not everyone will be
working on a weight
1. Cultivate Champions goal. Instead, teams
For clinicians and staff, AIM-HI is a personal venture. can compare steps
Identify a champion to conduct an initial staff meeting or miles walked,
to express the importance of personal fitness and the time spent in motion, Family medicine offices in the AIM-HI
desire to conduct this activity as a team. The champion food choices or calories research study created posters featuring
should emphasize the importance of AIM-HI, demonstrate in vs. calories out. staff members who had made changes for
leadership, and work to increase buy-in. better fitness. The posters were placed in
Teams can use one of exam rooms to introduce AIM-HI to patients.
Make it a collaborative process. Since the whole the many free online
practice will have an opportunity to improve their personal tracking systems, such as America on the Move
fitness using AIM-HI tools, use a collaborative process that (www.americaonthemove.org). Online tracking systems
allows all staff and clinicians to plan how best to work as a are an excellent resource to track team involvement and
team while committing to personal processes of change. success, and are also great for patients.
Your practice may want to form a committee to assist the
ChooseMyPlate.gov provides practical information to
champion in developing and implementing the project.
individuals, health professionals, and health educators to
help patients build healthier diets. The website includes
2. Develop a Fitness Culture and resources and tools for dietary assessment, nutrition
Show It Off! education, and other user-friendly information.
There are numerous ways to develop and establish a
fitness culture. The important part is getting the entire staff
thinking and talking about fitness among themselves and
with patients. Examples of how to demonstrate your fitness
culture include:
• Wearing identity items (t-shirts, pedometers, buttons)
that promote fitness and elicit questions from patients.
• Placing visual cues, such as posters, placards and table
tents, that show fitness is a priority for the practice.
3
AIM-HI Works!
AIM-HI Works!
5. Use the Tools
Creating a healthy office means clinicians and staff
AIM-HI Works!
personally use the tools that patients will use. Use of the It helps that I have co-workers
Fitness Inventory and Food & Activity Journal will provide who are doing the same things
your staff with first-hand knowledge of how best to use to change their lifestyles.
these tools with patients. Using tools as a group will allow Janette Richardson
your practice to share personal goals, success stories and Front Office Receptionist
challenges faced in each of your personal campaigns to Alcona Health Center
Lincoln, MI
improve fitness.
Ideas for Creating a Healthy Office
A number of family medicine offices have already worked to create a healthy office. Below are some of their
suggestions for working together to create a culture of fitness.
Increase Movement
• Start an office walking group at lunch time.
• Use stairs daily or more frequently.
• Join a fitness center (have the practice pay or offset costs through a shared plan!).
• Create a buddy system for working out.
• Use a gym or track at a nearby school.
• Hold physical activity, yoga, or dance classes for staff/patients/non-patients who are interested;
hold them in the waiting room during non-patient hours.
• Participate in local walks/runs as a practice team.
• Purchase pedometers for staff.
• Go bowling together.
Improve Healthy • Install a water cooler in break rooms and waiting rooms.
Eating • Change from sweetened tea to unsweetened tea.
• Start a “healthy lunch” program, providing a healthy lunch for the entire office.
• Change the nutritional quality of snacks brought by staff and clinicians.
• Request that pharmaceutical representatives bring in healthier foods.
• Share healthy recipes.
• Post a chart showing the number of calories in various portions of fast foods.
Publicize Your Efforts • Make posters about competitions and put them outside the employee lounge.
& Successes • Post a scoreboard for teams’ successes on the practice website.
• Post easy-to-read BMI charts in all patient areas.
• Get a local newspaper to do a story about your fitness efforts.
• Develop an information board that highlights one staff member’s fitness activities each week
(or one patient’s activities).
• Hang completion certificates in well-traveled hallways.
• Place AIM-HI literature in break/lunch room.
Incorporate Patients • Challenge patients to walk 10,000 steps with you.
• Wear a pedometer and use it as a prompt for discussing fitness with patients.
Develop Educational • Present work-time seminars about fitness.
Opportunities & • Have clinicians give weekly or monthly lectures on healthy tips, goal setting and weight loss basics.
Incentives • Use the America On the Move website.
• Provide prizes for teams.
• Provide time for fitness in-services.
• Allow staff to flex schedules to accommodate fitness breaks.
• Allow staff to adjust job responsibilities to cover AIM-HI program responsibilities.
• Start a staff “biggest winner” competition (focus on healthy eating, physical activity or pounds lost).
4
Integrating Fitness Into Your Practice
This part of the AIM-HI manual will help you think about
how your office works and how you can make small
changes to encourage clinicians and staff to integrate
fitness into your practice.
1. Assess Your Practice’s Environment
Your practice can demonstrate a commitment to fitness and
facilitate patient-centered conversations about fitness by
proactively setting up the physical environment to support
fitness. Conduct a brief, informal assessment of your practice.
Examine your policies, procedures, equipment, etc. by using
these assessment questions;
Checklist for Office Environment 1. How does your practice encourage patients to engage in
behavior change for:
Does the waiting room have the following culturally
appropriate materials? • Physical activity?
Fitness health guides or educational materials • Healthy eating?
Fitness posters • Emotional well-being?
Fitness magazines Examples may include distributing educational materials,
Audio/video displays referring patients to behavior change classes, and
employing behavior change specialists, such as health
Do exam rooms or areas adjacent to exam rooms educators and dietitians.
have the following?
2. How does your practice environment currently
Tape measure (for waist circumference promote fitness?
measurements)
3. Imagine that your practice is successfully doing everything
Scales with a capacity of more than 300 pounds
it can to promote fitness. How might that look?
Scales located in private area
Sturdy exam tables and chairs to accommodate 4. What are some of the challenges to promoting fitness in
large patients your current practice routine?
Gowns for people of different sizes 5. What has worked in terms of promoting fitness in your
Body Mass Index measuring tools practice? What hasn’t?
Adult BMI chart 6. What policies, procedures, and systems do you have in
BMI-for-Age instruction guide place for promoting fitness?
Growth and BMI charts for children and teens 7. What roles and responsibilities do staff have in promoting
ages 2 to 20 fitness?
Fitness posters
8. What community resources are available for patients?
List of local resources
9. How do you link patients to community resources?
Do you have established procedures 10. What fitness promotion services and activities
(protocols) for: (with patients) does your practice document?
Following the Adult Obesity Clinical Guidelines 11. What areas would you like your practice to improve as it
Distributing patient education materials relates to promoting fitness?
Starting a conversation about fitness
Documenting fitness promotion
Following up with patients
Evaluating fitness promotion activities
5
2. Be Sensitive to Obese Patients’ Needs
Clinicians and staff in your practice may want to spend some time becoming
aware of their own biases, developing empathy and working to address the
needs and concerns of overweight and obese patients.
Create a supportive environment with large, armless chairs in waiting rooms,
adequately-sized medical equipment and patient gowns, and friendly patient
AIM-HI Works! reading material.
AIM-HI Works! You also may want to examine your own biases about weight. Ask yourself:
1. Do I make assumptions regarding a person’s character, intelligence,
AIM-HI Works! professional success, health status, or lifestyle behaviors based only on
I AIM-HI
had health concerns.
Works! I realized that the person’s weight?
my concerns would get worse if I didn’t 2. Am I comfortable working with people of all shapes and sizes?
make changes. My doctor treated me
with medication and encouraged me to 3. Do I give appropriate feedback to encourage healthy behavior change?
be more active. I started a new job at a 4. Am I sensitive to the needs and concerns of obese individuals?
family medicine practice, where fitness
was a focus. That helped me to be even 5. Do I treat the individual or only the condition?
more motivated. I am (now) the most fit Recognizing and reducing stigma about weight in your own practice will make
I’ve ever been in my whole life. My energy your office a more patient-centered practice.
level has increased and I have an overall
feeling of wellness.
3. Adjust Office Processes and Procedures
Teri Archuleta
Medical Receptionist
Consider how you might modify your current office processes to integrate
Silver Sage Center for Family AIM-HI. Successful integration of AIM-HI into your practice routines will promote
Reno, NV sustainability of the program, help staff think about fitness issues as a part of
AIM-HI Works! clinical care (not just an educational add-on), and create an environment that
AIM-HI Works! supports fitness.
AIM-HI Works! Evaluate Patient Flow
AAIM-HI
year and a half ago, my doctor told me Take a moment to examine how patients flow through your office and
Works! consider each of the AIM-HI tools (Fitness Inventory, Fitness Prescription and
I had congestive heart failure. I was 35.
My daughter was 7 years old. I thought, Food & Activity Journal). This will help you identify opportunities for patients
“If I don’t change my eating habits and to be exposed to fitness promotion messages and receive adequate support
get off the couch, she won’t have a from staff. Questions you may want to consider include:
mother.” I started walking after work. I • What happens when patients enter the clinic?
eat when I am hungry and incorporate
• Who do patients see before seeing the physician?
small snacks, so I don’t over-eat. I have
lost 20 pounds and my progress has been • What happens to patients when vital signs are measured?
an incentive for others to make wise • What information is exchanged with patients before the patient-clinician
choices for a healthy lifestyle. I am no encounter?
longer on heart medication. • What happens when patients see the physician?
Wanda Harris
Front Office Supervisor • How do clinicians support fitness during the encounter?
Berkeley Family Practice • What services are documented, and how?
Moncks Corner, SC
• What reminder systems and prompts are in place to alert clinicians of
opportunities to discuss fitness?
• What happens when patients exit the clinic?
6
Change the System
Determine specific points where you can modify your office Get Started With the AIM-HI Tools
procedures to create opportunities to make sure each After you have evaluated your practice’s current
clinician and staff member understands his or her role and physical environment and resources and considered
responsibilities. how you might make changes to better support
• Incorporate the AIM-HI Fitness Inventory into periodic fitness in your practice, you are ready to begin
screenings. using the AIM-HI tools with patients. We recommend
developing a specific implementation plan.
• Put AIM-HI patient education materials in your reception
area and exam rooms. 1. Ensure that all staff and clinicians know about
• Add BMI and waist circumference to routine vital sign AIM-HI and their role in sharing tools with patients.
measurements. Hold an in-service training session to motivate staff,
promote teamwork and help formalize the protocol
• Add system prompts/reminders for clinicians to address
for delivering AIM-HI. For example, you can:
fitness with patients.
• Share information that you gathered during your
• Provide billing staff the information on reimbursement and
practice assessment.
coding.
• Document and
• Offer staff continuing education opportunities. AIM-HI Fitness Inventory
evaluate fitness Name:__________________________________________________________ _ Date:_______________________
• Provide regular updates and feedback to staff. promotion.
We understand that physical activity, healthy eating and emotional well-being are an important part of your health.
We want to partner with you to achieve your goals in these areas.
Please answer the following questions to help us better understand your interests and needs in these areas.
(Please note: we will work with you on these issues over time and may not attempt to address all of them in
Food & Activity Journal
this office visit.)
• Establish a feedback mechanism with health clubs or • Follow up with
How_Active_Are_You?
Please select the one choice that best describes you:
_I’m_physically_active_already_and_don’t_need_help_to_be_more_active._
_I’m_ready_to_get_more_active_and_would_like_help.
weight management programs to track patients who have
AIM-HI FITNESS PRESCRIPTION
_I’m_not_sure_if_I’m_ready_to_be_more_active,_but_I’m_ready_to_talk_about_it.
_I’m_not_very_active_and_not_interested_in_being_more_active_at_this_time.
Patient name:___________________________________________ Date:___/___/_____
patients.
Physical Activity Healthy Eating Emotional Well-Being
1) How many hours each day do you spend Opportunity
watching TV or videos or on the computer?
less than 1 1-2 (What do Imore
want than 2
to do?)
been referred by your office. 2) How many times a week do you do yard or
4 or more 1-3
Goalhouse work or duties on the job that cause you to work up a sweat?
(My target)Less than 1
2. Decide how
Dose
3) How many times a week do you get out for
(Howamuch,
brisk walk of 10 minutes or more?
how often?)
4 or more 1-3 Less than 1
Benefits
(What’s in it
Consider how your clinic can incorporate system triggers
4) How many times a week do you participate in sports or an exercise program?
for me?)
4 or more 1-3 Less than 1
Personal Goal(s):____________________________________________________________________
each tool
Use the Food & Activity Journal and bring it back to the next visit. For more information visit
www.familydoctor.org.
Next follow-up visit scheduled for:__________________________________________
Physician signature: _______________________________________________________
to encourage and support patients, clinicians and staff.
Patient signature: _______________________________________________________
(AIM-HI Fitness
Prompts can include:
Inventory, Fitness (turn_over)
© 2007 American Academy of Family Physicians
© Copyright 2007 American Academy of Family Physicians
• The AIM-HI Fitness Inventory, which will provide a starting Prescriptions and
point for conversations Food & Activity
• Automated alerts on charts of patients with conditions Journals) will be delivered to
affected by lifestyle choices and used with patients.
• Weight management or lifestyle DVDs played in the 3. Strategically place AIM-HI materials throughout
reception area your office and make them visible to patients, staff
• Staff pedometers that can be used as prompts for fitness and clinicians.
conversations. Challenge patients to walk 10,000 steps Learn more about using the AIM-HI tools on page 14.
with you.
Patient Visit Flow Chart
Clinicians:
Front Office Staff: Patient • Refer to the Adult Obesity Clinical Guidelines.
• Hand patient AIM-HI Checks in • Ask if patient is willing to discuss lifestyle changes today.
Fitness Inventory. • Review completed AIM-HI Fitness Inventory.
• Discuss BMI, waist circumference. Front Office Staff:
• Stay alert for opportunities to discuss fitness • Remain available to answer
(e.g., when talking about chronic conditions). fitness questions or provide
Nurses or Medical Assistants: • Use Fitness Prescription to help patient set goals. fitness resources.
• Calculate BMI. • Plan follow up intervals. • Schedule referrals and
• Measure waist circumference. • Ask patient to complete Food & Activity Journal. follow up appointments.
• Explain why these (BMI, • Document appropriate information in charts.
waist circumference) are done. Patient
• Review AIM-HI Fitness Inventory Vital signs meets with Patient leaves
and screen issues for clinician checked clinician
to address.
Nurses or Medical Assistants:
• Introduce or remind patients
• Remain available to
about AIM-HI tools.
answer fitness questions.
7
4. Establish a Referral System
Centers for Disease Control and Prevention data indicate that
patients are three times more likely to undertake a weight loss
program if a clinician suggests that they do so. While you and
your staff may not have all the answers or resources a patient
needs, there is help available. Find out about resources in your
community and develop a fitness referral list that includes:
• Registered dietitians
• Health educators
• Physical activity centers
• Personal trainers
• Walking groups
• Wellness centers
• Psychologists
• Therapists
Remember, not all referrals will be weight-based. Also
AIM-HI Works! keep in mind that out-of-pocket costs may be a barrier
AIM-HI Works! for some referrals. Below are two referral resources
developed in cooperation with the AAFP:
Six years ago, Works!
AIM-HI I was diagnosed with diabetes at
age 29. I had to start taking medication to control • Age-friendly Fitness Locator (www.icaa.cc/
it.AIM-HI facilitylocator.htm) — The International Council on
For more thanWorks!
17 years, I had struggled to lose
weight and had been on every yo-yo diet imaginable. Active Aging (ICAA) created a special section of its Web
I finally realized that my emotions played a part in site to help physicians quickly locate fitness and wellness
what I eat. I learned not to reach for food in order to facilities dedicated to serving adults fifty and older.
deal with stress. After physical activity, I feel much • Medically-integrated Fitness Centers
better and am able to deal with any problems. Also (www.medicalfitness.org) — The Medical Fitness
helpful are the Clinic Health Education Department Association Web site has a search tool for locating fitness
tips and AIM-HI’s Food & Activity Journal and Health centers dedicated to improving outcomes for patients
Guide. My cholesterol is normal now and I am with chronic diseases.
completely off all medication! It’s been two years • Registered Dieticians (www.eatright.org) — Visit the
and I’ve lost 64 pounds. American Diabetic Association Web site to locate a
Liz Villasenor registered dietician.
Staff Accountant
The Children’s Clinic
Long Beach, CA 5. Get Paid (Reimbursement)
There are diagnosis codes for obesity (278.00, “Obesity,
unspecified”), morbid obesity (278.01) and overweight (278.02).
However, payment for these diagnoses is very limited. Some
insurance carriers routinely deny claims with a primary
diagnosis of obesity or overweight.
The most consistent way to get payment for the services you
provide is to bill for the management of the numerous co-
morbidities associated with overweight and obesity. If the chief
purpose of the visit is to manage co-morbid conditions, the
codes for the conditions should be listed first.
Some private insurers will pay for medically necessary
physician supervision of weight reduction programs if
members have a documented history of failure to maintain
a reasonable weight and BMI, or if the member has
specific co-morbidities. You should check with payers
before billing for this.
8Some private insurers consider nutritional counseling Communicate with payers proactively to find out if they will
medically necessary for chronic disease states in which dietary pay for preventive and problem-oriented services provided on
adjustment has a therapeutic role. The counseling must be the same date. Medicare requires that you deduct the amount
prescribed by a physician and furnished by a licensed health of the problem-oriented service from the cost of the preventive
professional recognized under the plan. Again, consult with service provided on the same date. If an insurer won’t pay for
individual payers before providing this service. both the preventive and problem-oriented service, you may
want to report only the one that is the primary focus of the
Billing Based on Time visit and requires the greatest amount of your time. Another
If you spend more than half of the face- to-face time with a option, if the condition doesn’t require immediate attention,
patient in counseling and coordination of care activities, the is to complete the preventive servcies exam and have the
level of evaluation and management service provided may be patient schedule a follow-up visit ot address the problem.
chosen based on time. Counseling is defined as discussion The Affordable Care Act eliminated cost-sharing for most
with a patient and/or family concerning one or more of the preventive services covered under Medicare and other
following areas: payers, effective January 1, 2011. The preventive services to
• Diagnostic results and/or recommended diagnostic studies which the provision applies are those that are appropriate for
• Prognosis the individual and that are recommended with a grade of A or
• Risks and benefits of management (treatment) options B by the US Preventive Services Task Force for any indication
• Instructions for management (treatment) and/or follow up or population.
• Importance of compliance with chosen management
(treatment) options Welcome to Medicare Exam and Annual Wellness Visit
• Risk factor reduction All beneficiaries enrolled in Medicare Part B are eligible for a
• Patient and family education “Welcome to Medicare” physical examination. This one-time
Thus, time spent with the patient discussing the potential visit has to be performed within one year of the beneficiary’s
benefits of lifestyle changes that may lessen the risks Medicare Part B enrollment.
associated with or help in the management of their The “Welcome to Medicare” exam includes a review of the
diagnosed condition would be considered counseling. patient’s medical and social history, including their diet,
Patients may be seen in follow up visits by staff, incident to physical activity history and body mass index; education on
the clinician, for services such as recheck of blood pressure. prevention; counseling on diet if the patient is overweight;
These follow up visits may be reported with code 99211 as and referral to other covered services.
long as they are medically necessary. Medicare will cover a new annual wellness visit and will
provide payment for the creation of a personalized prevention
Billing for Preventive Services plan. The wellness visit will include a health risk assessment
Many insurers pay for preventive medicine service visits. and may include health education or preventive counseling
These can include a risk factor review; an age and gender services designed to reduce risk factors that have been
appropriate history (personal, social, and family) and exam; identified during the visit. Details are available on the
and counseling and guidance to reduce risk factors. A CMS web site at http://www.cms.gov/MLNProducts/
preventive service visit provides a prime opportunity to downloads/Annual_Wellness_Visit.pdf .
counsel patients on nutrition and physical activity.
A preventive services visit is not problem-oriented and does Group Visits
not involve a chief complaint. If, during the preventive visit, In most instances, group visits are not
your patient presents a significant new complaint or a chronic specifically covered by Medicare or most
condition that requires you to perform the key components of private health insurance plans. However,
a problem-oriented visit, then you can use both a preventive Masley et al. have been successful in
visit code and a problem-oriented visit code. The problem- documenting and billing for services
oriented service should be clearly documented and distinct performed for individual patients. Use
from the documentation of the preventive service, and an appropriate level office visit code
you should append modifier 25, “significant, separately (99212-99215) based on the individual patient’s diagnosis,
identifiable E/M service by the same physician on the same history, exam, and the medical decision-making you document.
day” to the appropriate office visit code. Link the appropriate Learn more about group visits in “A Guide to Group Visits
ICD-9 code to the applicable CPT code to distinguish for Chronic Conditions Affected by Overweight and Obesity”
between preventive and problem-oriented services. available in the AIM-HI resources section of the Americans In
Motion website at www.americansinmotion.org
9Working With Patients
The Patient-Centered Conversation
This section of the AIM-HI manual covers how you can use A major component to any conversation is assessing
the AIM-HI tools and philosophy to help patients improve patients’ attitudes and readiness to change. The AIM-HI
their fitness. Fitness Inventory promotes patient-centered conversations
by helping you and your staff assess and consider
patients’ attitudes and readiness to discuss changes in
The Teachable Moment lifestyle choices. As you capitalize on teachable moments,
The AIM-HI approach focuses heavily on recognizing, your actively engage patients in conversation to determine
creating and capitalizing on “teachable moments.” A areas where they would like to focus, how they would like
teachable moment is a point in a patient visit where you to proceed, and what their personal goals are.
are able to reshape the conversation from advice-giving
Motivational interviewing is goal-directing counseling to
to shared decision-making. This opportunity often arises
motivate behavior change. Motivational interviewing uses
when patients are presented with information that requires
the OARS technique to help patients move through the
them to attend to or process new information. Capitalize
stages of change. OARS is an acronym for:
on teachable moments to discuss healthy lifestyle choices.
Some key opportunities include: • Open-ended questions
• New patient visits • Affirmations
• Annual physicals • Reflective listening
• Women’s wellness exams • Summaries
• Well-child exams When using the OARS technique to talk to patients
about fitness:
• Group visits
• Express empathy — When patients think you’re listening
• Problem-oriented office visits for the many diseases to them and understand their concerns, they’ll be less
influenced by lifestyle choices defensive and may be more likely to open up. As they
The goals of a fitness conversation are to: talk, you can assess where they need support.
• Build a dialogue that is patient-centered and focused on • Support self-efficacy — Make your patients responsible
the total patient for identifying the changes they want to make. Focus your
• Bring about a desire for behavior change and eliminate attention on helping them believe that they can change.
resistance when dealing with lifestyle and personal change Point out previous successes they have had, or how other
patients have successfully changed.
• Approach change through realistic, measurable
goal-setting • Roll with resistance — Don’t challenge patients who resist
change. Instead, ask them what their solution is for the
• Improve continuity of care problem they’ve identified.
• Develop a plan together that ultimately places the • Develop discrepancy — Help patients see the discrepancy
patient in the position of power between where they are and where they want to be.
Visit www.motivationalinterview.org for more information
about motivational interviewing.
AIM-HI Works!
AIM-HI Works!
AIM-HI Works!
One of our patients
AIM-HI Works!has significantly improved his health in the last 7 months by making reasonable
changes in his eating and activity. He is 58 years old and started with a BMI of 33. On recheck today he
has lost 20 lbs, decreased his BMI to 30, dropped his diastolic blood pressure from 96 to 78, and improved
his LDL cholesterol from 111 to 85. His success has helped encourage me to keep talking to patients about
making healthy changes. When someone is really ready to improve his or her life, I am armed and waiting.
Vance Blackburn, MD
North Shelby Family Health
Birmingham, AL
10Stages of Change
The Stages of Change model delineates the stages people go through when making a change in behavior. The
following shows how you can use a patient’s stage of change to have a patient-centered discussion about fitness.
Patient Stage of Discussion Topics Example Questions Recommended Patient
Characteristics Change Education Handouts
Not currently Pre- Discuss the potential • How do you feel about your
interested or contemplation benefits of lifestyle changes health these days?
considering change, and indicate that you are • Would you consider me a
“ignorance is bliss” available if and when they resource if you decide to make
are ready to discuss it changes in the future?
further.
Open to making Contemplation Discuss some of the • Are you willing to make some • Every Little Bit Counts
changes for better changes they could make changes to improve your • One Step at a Time
health at this time, and help them set an cholesterol levels?
“sitting on the fence” achievable goal (e.g., eat • All Foods Fit
• What would you like to do to try
more fruits and vegetables, to simplify your life? • Life Balance
make time for exercise or
gain more “me” time for • Would you be open to exploring
hobbies, etc.) a couple of ways to be more
active every day?
• What are some things you could
see yourself doing to relax?
Ready to commit Preparation Let patients decide what • What would you like to see come • Food & Activity Journal
to changes, their goals are. The out of trying to eat better? • One Step at a Time
“testing the waters“ emphasis should be on • Getting Started
• What do you want out of this?
the patient’s goal and how
he or she can make small • Overcoming Physical
changes in daily life for Activity/Exercise Obstacles
meaningful, lifelong results. • Am I Hungry?
• End Mindless Eating
• Search Your Shelf
Already doing Action Offer support, referrals and • You seem healthier than you • Food & Activity Journal
something to tools. Anticipate challenges were at our last visit. Have you
• Overcoming Physical
improve their health, and setbacks and discuss been doing anything different?
Activity/Exercise Obstacles
“Charge!“ ways to handle them. • You look really fit today. Tell me
• Fat Facts
what you have been doing since
I last saw you. • Think Your Drink
• You seem to be in a good mood • Search Your Shelf
today. Tell me what you’ve been • Manage Your Stress
up to.
AIM-HI patient education handouts are available at www.americansinmotion.org.
Key Reminders: 4. State that you are willing to provide ongoing support
1. Keep in mind that patients will be at different stages of and encouragement.
change. Therefore, each conversation must be 5. Refer patients to community resources to help them
individualized. build on the efforts they make toward better health.
2. The goal is to facilitate discussion and enable patients As you enable patients to take charge of their own health
to determine their own solutions for improved health. and make healthy decisions, you may want to offer additional
3. Allow patients to share reasons for or against change resources to let them explore healthy changes they can make
and how their current lifestyle choices may support or after the visit. AIM-HI patient education handouts are available
conflict with their health goals. online at www.americansinmotion.org/education in
the AIM-HI Resources section.
11Talking With Overweight and 3. Explore all causes of presenting problems, not just weight.
Obese Patients 4. Recognize that many patients have repeatedly tried to
Be sensitive when talking to patients. Some specific strategies lose weight.
recommended by the North American Association for the 5. Emphasize behavior change rather than just the number
Study of Obesity (www.naaso.org) include: on the scale.
1. Consider that patients have probably had negative 6. Negotiate concrete changes (e.g., start to add movement
experiences with other health care professionals regarding by walking for 30 minutes and eat at home three or more
their weight. Approach patients with sensitivity. times a week), rather than simply saying, “You need to
lose weight.”
2. Recognize the complex etiology of obesity. Communicate
this to colleagues and patients to avoid stereotypes that 7. Acknowledge the difficulty of lifestyle changes.
obesity is attributable to personal willpower. 8. Recognize that small weight losses can result in significant
health gains.
The Eating Cycle
Help patients learn to distinguish their biological need for food from the
emotional or environmental cues that trigger an urge to eat or overeat.
Use these questions and bite-sized messages to talk to patients about
their eating cycles.
The Eating Cycle was developed by family physician Michelle May, MD, FAAFP.
For more information go to www.AmIHungry.com.
Decision Possible Questions to Start the Conversation Bite-sized Messages
Why? • Why do you think you eat? • Instinctive Eating Cycle: Hunger is the primary reason
Why do I eat? • Are you aware of any situations of emotions for eating; it is a primitive yet reliable regulator of fuel
that trigger you to want to eat when you aren’t intake.
hungry? (Examples: mealtimes, ballgames, • Overeating Cycle: Environmental and emotional cues
certain people, stress, boredom, buffets, getting can trigger an urge to eat (or to continue eating) whether
ready to start a diet) there is a physical need for fuel or not.
• Have you tried a lot of diets? What happened? • Restrictive Eating Cycle: Diets can lead to
How did they work for you long-term? Why? preoccupation with food and feelings of deprivation
that eventually lead to rebound overeating.
When? • When do you feel like eating? • Ask yourself, “Am I hungry?” whenever you feel
When do I feel • How can you tell when you’re hungry? like eating. (Help patients develop an internalized
like eating? mechanism of knowing when to eat.)
• How could you distract yourself from eating until
you get hungry? • Hunger is a physical feeling; it is not the same thing as
cravings, appetite, or a desire to eat.
• What could you do to cope more effectively with
your emotional triggers for eating? For example: • Getting too hungry can be a trigger for overeating.
manage stress better, find a hobby, treat yourself to • Identify and reduce environmental cues for
a hot bath, ask for help around the house. overeating. For example putting food out of sight,
AIM-HI Works! avoiding areas like the break room where food
is likely to be found and ordering half-portions or
AIM-HI Works! sharing meals.
• Identify and cope with emotional triggers for
Instead
AIM-HI of focusing on what and how much food
Works! overeating such as boredom, stress, sadness, anger,
you should eat, the key is first understanding why loneliness, celebrating, or rewarding yourself. (Refer
AIM-HI
you want to eatWorks!
in the first place. This awareness as needed).
will give you the opportunity to meet your true
needs appropriately.
Michelle May, MD, Phoenix, AZ
12Decision Possible questions to start the conversation Bite-sized Messages
What? • What do you eat in a typical day? • All Foods Fit: There are no “good” foods or “bad” foods.
What do I eat? • Do you restrict yourself from eating certain foods • Use balance, variety and moderation to guide your
then later give-in and overeat those foods? choices. www.mypyramid.gov provides a good general
• Are there any areas of your diet that you think could guide to healthful eating.
be improved? Balance — provide your body with the necessary
• What specific change(s) would you like to make? nutrients by balancing eating for nourishment with
eating for enjoyment.
• What health issues do you need to be aware of
when choosing food (h/o high cholesterol, family Variety — eat foods from all of the food groups and a
h/o diabetes, BMI > 25, etc.) variety of foods within each group.
• What kinds of beverages do you drink? Moderation — consider overall dietary intake, not just
the portion size of one particular item.
• What types of food do you want to eat when you’re
eating for emotional reasons? • Ask yourself three questions when deciding what to eat:
What do I want? What do I need? What do I have?
• What kinds of food could you keep on hand to eat
when you are hungry? • Make small, focused, incremental changes. For
example, increasing fruits and vegetables, improving
the quality of the fluids you drink, lowering your
saturated and trans fat intake and switching to
healthier fats.
How? • Do you eat while distracted? For example, watching • Eat mindfully: Stay aware of your body, the food, and
How do I eat? TV, driving, working. the ambience.
• Do you think you eat quickly? • Minimize distraction: Turn off the TV, eat while seated
• Do you eat differently in private than you do at a table.
in public? • Savor each bite, noticing the appearance, aromas
and flavors.
• Put your fork down between bites.
How Much? • How do you typically feel after eating? • Your stomach is only about the size of your fist so it
How much do I • How does it feel when you have eaten too only takes about a palm-full of food to fill it.
eat? much food? • Eating too much can cause you to feel uncomfortable
• What situations or emotions trigger overeating and sluggish. (Help them develop an internalized
for you? mechanism of portion control.)
• What could you do to address those triggers more • When you eat more than your body needs, it has no
effectively? For example, order less food, get up choice but to store the extra fuel.
from the table, turn off the TV, etc. • Practice ending your meal when you are satisfied
instead of stuffed.
Where? • Where do you spend (or invest) the fuel • The food you consume provides the energy and
Where do you consume? nutrients to live, work, play and exercise.
I invest my • Are you physically active? • When you eat more than you need, the excess fuel
energy? • Do you limit your “screen time?” will be stored to be used for fuel later.
• Do you exercise? What do you like to do? • Increased physical activity in daily living can have a
significant impact on your fuel balance.
• What else do you do? For example, do you like
to play with your children, have hobbies, volunteer, • Exercise will improve your health, increase your
or travel? stamina and function, and make you feel better.
• Is there anything else you would like to do that you • When you invest your energy in living a full,
are not doing now? What are your goals for your balanced life, you are less likely to use food to meet
relationships, career, and life? your needs, therefore breaking an Overeating and
Restrictive Eating Cycle.
13The AIM-HI Fitness Inventory
and Fitness Prescription
The AIM-HI Fitness Inventory captures patients’ confidence about their
personal fitness. It also provides a snapshot of their readiness to change
and desire for help.
Whether a patient is underweight, overweight, suffers from a chronic
disease, or even appears to be healthy — he or she should be encouraged
to consider choices that will lead to a healthier lifestyle. The AIM-HI Fitness
Prescription can help you and your patient create a plan for better fitness.
How to Use the Fitness Prescription
and Fitness Inventory
1. Have your front office staff ask the patient to fill out the AIM-HI Fitness
Inventory at check-in.
2. Review the inventory before entering the room.
AIM-HI Works! 3. During teachable moments, use the answers on the inventory to
AIM-HI Works! guide discussions. Ask open-ended questions such as, “What are
you interested in focusing on at this time? Physical activity? Healthy
I AIM-HI
especially likeWorks!
the AIM‑HI Fitness Prescription eating? Your emotional well-being?”
because the patient picks something specific
toAIM-HI 4. Use the Fitness Prescription to record a few realistic, actionable, and
Works!
work on to improve his/her fitness, sets a
sustainable changes. Make sure the patient makes the decisions on what
goal, and knows what the positive outcome
can be. It gives me talking points for behaviors to change.
motivational interviewing each time the patient 5. Sign the Fitness Prescription and have the patient sign it as a statement
has a follow‑up visit. Patients are so proud of of your mutual commitment to working together.
the changes they are making! 6. Record what was discussed and what was written on the Fitness
Carol O’Connor, RN, CDE Prescription, including the plan for follow-up, in the patient’s record.
Health Education Director
Alcona Health Center 7. Keep a copy of the Fitness Inventory with the patient’s record. Have the
Lincoln, MI patient complete a new inventory at least once a year.
8. Follow up at the next visit.
Food & Activity Journal
Encouraging a patient to keep a Food & Activity Journal will help him or her
become more aware of current behavior, patterns, and choices made each
day related to eating and physical activity. Awareness is an important part
of making lasting changes for healthy living. The Food & Activity Journal is
a practical tool patients can use to record their observations about physical
activity, nutrition, and emotional well-being.
AIM-HI Works! Ask your patient to complete this journal and bring it back to their next
AIM-HI Works! appointment. Emphasize that the purpose is awareness, not judgment.
Reinforce that using a journal is a proven tool for changing behavior and
I AIM-HI
love to use theWorks!
Food & Activity Journal and successful weight loss.
the patients love them as well. They provide
To order free copies of the tools, call 800-274-2237 or visit
AIM-HI
such good inputWorks!
on what exactly we consume.
americansinmotion.org and click on the AIM-HI resources section.
Patients have made dramatic changes in their
eating habits because of the journals they keep.
Imelda Meza, Medical Assistant
Chronic Disease Educator
The Children’s Clinic
Long Beach, CA
14AIM-HI Fitness Inventory
Name:__________________________________________________________ Date:_______________________
We understand that physical activity, healthy eating, and emotional well-being are an important part of your health.
We want to partner with you to achieve your goals in these areas.
Please answer the following questions to help us better understand your interests and needs in these areas.
(Please note: we will work with you on these issues over time and may not attempt to address all of them in
this office visit.)
How Active Are You?
Please select the one choice that best describes you:
I’m physically active already and don’t need help to be more active.
I’m ready to get more active and would like help.
I’m not sure if I’m ready to be more active, but I’m ready to talk about it.
I’m not very active and not interested in being more active at this time.
1) How many hours each day do you spend watching TV or videos or on the computer?
less than 1 1-2 more than 2
2) How many times a week do you do yard or house work or duties on the job that cause you to work up a sweat?
4 or more 1-3 Less than 1
3) How many times a week do you get out for a brisk walk of 10 minutes or more?
4 or more 1-3 Less than 1
4) How many times a week do you participate in sports or an exercise program?
4 or more 1-3 Less than 1
(turn over)
This form may be reproduced for use in clinical settings without permission from the authors or the American Academy of Family Physicians.
Americans In Motion - Healthy Interventions
15How Well Do You Eat?
Please select the one choice that best describes you:
I’m eating healthy at this time.
I’m ready to make some changes to eat healthier and would like help.
I’m not sure if I’m ready to change the way I eat, but I’m ready to talk about it.
I’m not interested in changing the way I eat at this time.
A serving of food is the amount that would fit in the palm of your hand.
1) How many servings of fruits or vegetables do you eat each day?
5 or more 3-4 2 or less
2) How many servings of whole grains (like whole grain bread or cereal, oatmeal, brown rice, etc.) do you eat each day?
3 or more 2 1 or less
3) How many times a week do you eat lean protein like chicken, turkey, fish, tofu or beans?
6 or more 3-5 2 or less
4) How many times a week do you eat high fat foods like fried food, pastries or chips?
1 or less 2-3 4 or more
5) How many times a week do you eat fast food meals or snacks?
1 or less 2-3 4 or more
6) How much margarine, butter or meat fat (lard) do you use in your cooking or put on bread, potatoes or other vegetables?
very little some a lot
7) How many sugary drinks (like regular soft drinks, sweet tea or fruit flavored drinks) do you drink each day?
none 1-2 3 or more
8) How many times a week do you eat desserts or other sweets?
3 or less 4-6 7 or more
9) How often do you eat when you are not hungry, for example out of habit or for emotional reasons?
Rarely Sometimes Often All the time
How Happy or Satisfied Are You?
Please select the one choice that best describes you:
I’m happy and satisfied with my life at this time.
I’m ready to make some changes to be happier and would like help.
I’m not sure if I’m ready to work on being happier, but I’m ready to talk about it.
I’m not interested in working on my happiness or satisfaction at this time.
In the last week, how often did poor physical or emotional health keep you from doing your usual activities?
Not at all Some days Most days Everyday
How often does stress or depression affect your ability to pursue healthy lifestyle changes?
Rarely Sometimes Often All the time
How many days per week do you participate in some form of a spiritual or cultural activity that gives you emotional strength?
Daily 3-6 days 1-2 days None
16AIM-HI FITNESS PRESCRIPTION
Patient name:___________________________________________ Date:___/___/_____
Physical Activity Healthy Eating Emotional Well-Being
Opportunity
(What do I want
to do?)
Goal
(My target)
Dose
(How much,
how often?)
Benefits
(What’s in it
for me?)
Personal Goal(s):____________________________________________________________________
Use the Food & Activity Journal and bring it back to the next visit. For more information visit
www.familydoctor.org.
Next follow-up visit scheduled for:__________________________________________
Physician signature: _______________________________________________________
Patient signature: _______________________________________________________ Americans In Motion - Healthy Interventions
AIM-HI FITNESS PRESCRIPTION SAMPLE
John Smith
Patient name:___________________________________________ 6 2 11
Date:___/___/_____
Physical Activity Healthy Eating Emotional Well-Being
Go for a walk or ride a bike. Ask yourself, “Am I hungry?” Read a book or go to a library.
E
Opportunity before eating. Try 2 cups in- Try yoga or deep breathing.
Use the stairs when possible.
L
(What do I want stead of 4 cups of coffee each
Wear a step counter to track day. Try 1 or 2 more fruits Go fishing.
P
to do?)
steps. Play a game. & vegetables, and dairy each day. Listen to music.
AM
Goal Be aware of what you eat.
Be more active every day. Relieve stress and relax.
(My target) Make mindful choices.
S
Dose At least 30 mins. a day or Eat only when hungry.
(How much, try 15 mins., twice a day. Stop eating before feeling full. Try to do something every day.
how often?)
Benefits More energy, quality time with Be in charge of eating
(What’s in it Reduce stress and take your
the kids, better health, less habits and choices. mind off things.
for me?) money spent on prescriptions.
Personal Goal(s):____________________________________________________________________
Use the Food & Activity Journal and bring it back to the next visit. For more information visit
www.familydoctor.org.
Next follow-up visit scheduled for:__________________________________________
Physician signature: _______________________________________________________
Patient signature: _______________________________________________________ Americans In Motion - Healthy Interventions
This form may be reproduced for use in clinical settings without permission from the authors or the American Academy of Family Physicians. 17You can also read
